Society has long placed white men at the top of leadership hierarchies across all fields, and medical science is no exception. Although much progress has been made to advance diversity in these roles, gender parity remains a serious leadership challenge in academic medicine. Achieving equity is a complex cultural and organizational change that will require acknowledgement of the privilege, recognition of the diversity among women, mentorship and sponsorship for women, and strong role models. Greater diversity in leadership will provide benefit from enhanced decision-making, reduced rates of harassment, improved collegiality, more accessible role models for women, and increased productivity.

There is increasing attention to the need for diversity in leadership, both to better reflect the societies we serve and to gain the benefits that arise from diverse leadership.1 Society has long placed white men at the top of leadership hierarchies across all fields and, although much progress has been made to advance diversity in these roles, this work is far from done. This is particularly true in science, technology, engineering, and medicine (STEM) and applies to both academic and clinical facets of medicine.2,3

Efforts to increase diversity in leadership roles have been directed toward both structural features (e.g., policies for recruitment and retention, opportunities for leadership development) and the ways in which unconscious bias affects who and what is privileged and, correspondingly, who or what is not. This complex cultural and organizational change also requires acknowledgement of the privilege that many of us in leadership roles do have and may take for granted. It is also important to acknowledge that many who have benefitted may experience the process of achieving equity as persecution, as initiatives related to diversity and inclusion are implemented.4 Top

Although we are interested in supporting all aspects of diversity in leadership, in this article, we focus primarily on women. Despite the ubiquitous and longstanding presence of women in the workplace, the perspective that childbearing and childrearing are the main issues that impede or affect the ability of women to move into leadership roles persists. However, we know that gender equity is a far more complex issue; childbearing and childrearing alone fail to explain the small number of women in leadership roles in academic medicine. As well, the emphasis on childbearing and childrearing fails to explain the wage gaps,5 the excessive criticism women receive when they fail as leaders, the exclusion of women from social networking opportunities other leaders have access to, institutional and professional community barriers, the lack of sponsorship for effectively naming women to leadership roles, or the fact that policies to date have not bridged these gaps fully or effectively.5–8

Women are not uniform. They are not all cis-gendered, married, with children, equally abled, white beings, and the intersectionality of these aspects creates, for some women, further disadvantage and difficulty in attaining leadership roles.9 Moreover, men are not a uniform category either, and further consideration about privilege and intersectionality will likely become increasingly relevant as subgroups of traditionally disadvantaged men lobby for their inclusion and equity in terms of leadership roles.

We also want to emphasize that, as women enter previously male-dominated STEM fields of study and workplaces, pre-existing and ongoing sexual harassment, even if ambient (an overall workplace culture and not targeted at a single person), is a significant barrier to advancement among both victims and female bystanders. Two key environmental factors that facilitate the expression of harassment in the workplace are male-dominated leadership and male-biased gender ratios.24,25

The incidence of harassment has held steady over the past three decades.26 This abuse is a potent distractor with an inverse relationship to work satisfaction for white women; for multiple marginalized women, gender harassment is compounded by other forms of harassment. Harassment is an issue that arguably has not received sufficient attention to date.27,28 How harassment affects decisions about moving into leadership roles and what happens when one is in a leadership role vis-à-vis harassmentneeds to be discussed and be part of how we move forward with initiatives to increase diversity in leadership.

What do we know? How does it apply?

Recent research has revealed three main reasons why women do not advance to top leadership roles despite their desire to move up: lack of role models, exclusion from informal social networks, and not having a sponsor in upper management to create opportunities.10 As well, attributes typically associated with strong leaders are culturally masculine, which may create challenges for women (and some men) who have a different leadership style — in terms of lack of recognition of the strengths of these alternative leadership models and feeling that they have not “measured up” or met expectations.11

In Canada, only two of the 17 deans of medical schools are women, despite equal enrolment of women and men in medicine for decades.12,13 As well, only 26% of university presidents in Canada are women.14 These numbers demonstrate just how few role models there are for women who are interested in becoming leaders. Girls grow up not seeing women in top leadership roles, which makes envisioning themselves in those roles or seeing this as a viable career path a challenge.15

Moreover, women are socialized to comply with rules and often do not consider applying for positions unless they meet 100% of the stated requirements, whereas men will apply with as few as 60% of the qualifications; thus, the climb to the top is potentially longer and more arduous for women.9,12 This disparity also raises questions about how qualifications are being evaluated across candidates and how required versus preferred criteria for leadership roles may send signals about what is valued as core skills.

Sponsorship too is lacking for women. A strong sponsor can give junior to mid-range faculty members the opportunity to showcase their abilities, highlighting leadership skills to others based on talent, while also gaining valuable experience. Talent-based recruitment and promotion has advanced, yet network-based recruiting remains common.16,17

In our own faculty of medicine (Dalhousie University), the dean struck a Diversity in Leadership Task Force in January 2017. This provided an opportunity to discuss and reflect on leadership culture within the faculty, looking at our own statistics as well as related faculty and university policies and processes, which culminated in a report and recommendations.1

The task force also undertook a research study to examine the experiences of faculty members, with an initial focus on gender and leadership. The goal was to identify mechanisms for increasing the diversity of our leadership, which included consideration of relevant barriers and strategies for career development. The results (pending publication) highlighted, among other things, the importance of understanding one’s local culture as a key factor in the attractiveness of and support for moving into leadership roles. Research participants, for example, discussed informal networks and perceptions of how these inform who is “selected” for key leadership roles. The research also reflected the above-identified broader conversations and concerns related to sponsorship/mentorship, policy implementation (including considerations related to childbearing and childrearing), and whether different leadership styles are acceptable and/

or welcome.

Why do (and should) we care?

The positive impact of diversity in leadership is indisputable, and the evidence for this is overwhelming.18–21 In sectors that are knowledge-centric, such as medicine and research, it is clear that diversity results in more creative thinking and innovation. Greater diversity in leadership provides benefit with respect to enhanced decision-making, reduced rates of harassment, improved collegiality, more accessible role models for women, and increased creativity and productivity in our work.22,23,29 In other words, focusing on diversity generally, as well as diversity in leadership, is not only an opportunity to address the moral issue of equity and inclusion, but it is also essential for productivity, better science, enhanced problem-solving, and making better use of public resources in academia and health care.

Conclusion

Mentorship is undeniably key in providing women the necessary support and advice they need to navigate leadership with its ups, downs, and unique challenges. However, talent recognition and sponsorship are also required. Without strong endorsement of talent and character, women too often remain unrecognized.

Consider the following. How diverse is your leadership group? What criteria were used for selection? Are a wide range of leadership styles and approaches embraced? Have these types of questions been discussed, and are there mechanisms in place to ensure diversity in leadership at your institution?

The need for diversity is not new. The skills and abilities of diverse leaders are not at issue; rather, dominant professional cultures need to demonstrate sustained, authentic commitment to change. Evidence shows that diversity will improve our outcomes, collaborations, and our bottom line. With this, we challenge all readers: what in the world are we waiting for?

Acknowledgements

We thank and recognize the other members of the Diversity in Leadership Research Group: Paula Cameron, Tanya MacLeod, Roger McLeod, Shawna O’Hearn, and Anna MacLeod. As well, we thank the Diversity in Leadership Task Force members, who are listed on the task force report. Top

As leaders in a faculty of medicine, one clinical and one academic, our paths to leadership have differed. Our backgrounds are distinct and yet our challenges and support in leadership are aligned.

Connie LeBlanc, MD

From a modest background with no medical exposure, I entered medical school at 19 years of age, prepared to work hard. However, I was ill-prepared for the nights of call and post-call days, some shifts over 36 hours, the various forms of harassment, and many other facets of the process. The harassment, studying in my second language, the evident affluence of my peers all saw me graduate stripped of some of the confidence and natural leadership skills I had previously developed.

Perhaps as a result of these experiences, I was surprised and excited as a new clinician to be asked to step into a leadership role by a mentor who saw talent invisible to me. My mentor supported me with careful measures of both clear direction and freedom. This sponsorship was essential; without it, I would never have applied, considered, aspired to, or had exposure to this exciting work.

Two decades later, I have worked on leadership skills: learning to stop and check, surround myself with diverse teams, engage in the challenge of meaningful and complex change, navigate conflict, strive to balance management and leadership, to move forward without leaving others behind. I have moved into more senior positions over the years and enjoyed each challenge along the way.

Leadership is not an easy path: the work is hard, the critics many. But, like every job, if the rewards outweigh the difficulty, the balance is right. Do not think that I have arrived; leadership is not like that. There is no finish line, no winner; it is rather a matrix of points and lines in a complex system heading, hopefully, in a direction that will leave the world, or at least my small part of it, a better place.

Christy Simpson, PhD

As a bioethicist, trained in philosophy, my interest always lay in being able to make a contribution to health care in terms of supporting others (patients, families, health care providers, leaders) in addressing the difficult questions that arise. When I was hired by the Department of Bioethics, Faculty of Medicine, Dalhousie University, this meant I could contribute to both health care and academia. A wonderful mix.

Being in a small department meant that I considered being department head at some point. As it turned out, the opportunity arose much earlier than expected — during a time of turbulent change and accompanied by high expectations. Although I received much support from the dean and other faculty, this was a period of rapid transition in relationships, priorities, and uncertainty about what was to come. Did I belong at the head table? What qualifications did I have? To whom could I turn with questions, whether mundane or major? Could I trust the information I was given?

I realized fairly quickly that one has a default leadership style, and mine was heavily and helpfully influenced by growing up on a dairy farm where I observed my parents manage, direct, and work over the years with hired people with different backgrounds and expectations. I was also in charge when my parents were not around and as my capabilities grew.

Now, after seven years as department head, one of the things I appreciate most is the opportunity to contribute to decision-making at the faculty level. It is one of the best ways to influence what can work better for everyone. Top